Health Questionnaire | Lisa Kim Lewis Yoga

Personal Information

Full Name: *

Emergency Contact Name: *

Date of Birth: *

Emergency Contact Phone Number: *

Relationship to Emergency Contact: *

Country of Residence: *

Health Information

Do you have any medical conditions that may affect your ability to participate in yoga, movement practices, or retreat activities? *

No
Yes

If yes, please describe: *

Are you currently under the care of a doctor or healthcare professional for any condition that may affect your participation? *

No
Yes

If yes, please provide details: *

Are you currently taking any medication that may affect your participation in yoga or physical activity? *

No
Yes

If yes, please provide details: *

Injuries & Physical Considerations

Do you currently have any injuries, physical limitations, or areas of discomfort we should be aware of? *

No
Yes

Examples may include:

back injuries
joint issues
recent surgery
mobility limitations
chronic pain

Mental Heath & Wellbeing

Retreats can sometimes bring up emotional experiences as well as physical ones. The practices offered during the retreat are intended to support general wellbeing and self-reflection but are not a substitute for medical, psychological or therapeutic treatments.

Are you currently experiencing any mental health conditions or emotional challenges that may affect your participation in the retreat? *

No
Yes (please provide details if you feel comfortable)

If yes, please describe anything you would like us to be aware of so that we can support your experience appropriately: *

Pregnancy

Are you currently pregnant? *

No
Yes

If yes, please indicate how many weeks pregnant you will be at the time of the retreat: *

Please note: participation in yoga practices during pregnancy should be discussed with your healthcare provider.

Dietary Requirements

Do you have any dietary requirements, allergies or food intolerances? *

No
Yes

If yes, please specify: *

Participating Acknowledgement

By attending the retreat, you acknowledge that:

Participation in yoga and retreat actvities is voluntary.
You are responsible for working within your own physical limits.
You will inform the teacher if you feel pain discomfort, dizziness or any other concerning symptoms during practice.
You confirm that you are physically and mentally fit to participate in retreat activities, or that you have sought appropriate medical advice if necessary.

Medical Consent

In the unlikely event of a medical emergency during the retreat, I consent to the organisers seeking appropriate medical assistance if required. *

I consent

Health Questionnaire Information